Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC)

摘要 姑息治疗可以减轻身心症状，提高生活质量，确保目标-- 为晚期癌症患者提供临终关怀。有持续和恶化的 非洲裔美国人患者临终结局的差异，这种差异被较低的可能性所混淆 使这些人口能够获得和接受姑息治疗。造成这些差异的基础是多因素的，而且在 生命的终结，障碍包括个人或文化价值观与临终关怀哲学相冲突，缺乏对 临终关怀服务、对家庭负担的担忧、经济因素和/或对医疗保健系统的不信任。 将具有细微差别的技能集的个人添加到护理团队，专注于解决此类护理障碍 是一种很有前途的方法，可以提高姑息治疗的接受度。社区卫生工作者(CHW)是非临床医生， 有文化能力的公共卫生工作者，他们的作用是促进获得服务，提供健康教育， 支持提供护理，并在服务不足的人群中促进宣传。社区卫生服务中心为患者提供补充护理 晚期慢性病，包括艾滋病毒/艾滋病、结核病和癌症，及其对改善的影响 这些环境中的护理是公认的。我们开发了一个综合的CHW模型--传播和 实施社区卫生工作者对姑息治疗差异的干预(决定PC)-- 利用CHW作为护理团队成员，为服务不足的患者增加姑息治疗结果 晚期疾病。在Decision PC中，CHW接受培训，以提供宣传、支持、激励 赋权，以及对病人及其照顾者进行姑息和临终关怀的教育。我们的 初步经验表明，社区卫生服务可以改善姑息治疗的结果，改善患者和 照顾者对护理的满意度。 我们的长期目标是减少晚期癌症非裔美国人在姑息治疗方面的差距。 将社区卫生工作者整合为医疗团队的成员可能是改善获得和 提高这一人群对姑息治疗的接受程度。为了探索这一点，我们将进行一项随机的 有效性-在四个不同的癌症中心实施务实试验，以1.比较 决定PC干预与标准护理在改善姑息治疗结果方面的对比，包括生活质量， 接收质量沟通、预先护理计划文档/讨论和临终关怀使用；2. 评估影响Decision PC干预的有效性、保真度和采用率的环境因素。 我们预计这项工作将优先确立基于CHW的姑息治疗干预的有效性 并产生可推广的知识，以指导干预措施的制定和实施 在服务不足的人群中增加对姑息治疗服务的使用。

SUMMARY Palliative care can reduce physical and psychological symptoms, improve quality of life, and ensure goal- concordant care at the end-of-life for patients with advanced cancer. There are persistent and worsening disparities in end-of-life outcomes for African American patients which are confounded by the lower likelihood of this population to access and receive palliative care. The basis for these disparities are multi-factorial, and at the end of life, barriers include personal or cultural values in conflict with hospice philosophy, a lack of awareness of hospice services, concern about burdening family, economic factors, and/or mistrust of the healthcare system. The addition of individuals to the care team with a nuanced skillset focused on addressing such barriers to care is a promising approach to enhance palliative care uptake. Community Health Workers (CHWs) are non-clinician, culturally competent public health workers whose role is to promote access to services, provide health education, support care delivery, and promote advocacy in underserved populations. CHWs supplement care for patients with advanced chronic diseases, including HIV/AIDS, tuberculosis, and cancer, and their impact on improving care in these settings is well-established. We developed an integrated CHW model – the Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DECIDE PC) – that utilizes CHWs as care team members to augment palliative care outcomes for underserved patients with advanced-stage illnesses. In DECIDE PC, CHWs are trained to provide advocacy, support, motivation, empowerment, and education regarding palliative and end-of-life care to patients and their caregivers. Our preliminary experience suggests that CHWs can improve palliative care outcomes and improve patient and caregiver satisfaction with care. Our long-term goal is to reduce disparities in palliative care for African Americans with advanced cancer. Integration of CHWs as members of the healthcare team may be an effective means to improve access to and enhance the uptake of palliative care in this population. To explore this, we will conduct a randomized effectiveness-implementation pragmatic trial at four diverse cancer centers to 1. compare the effectiveness of the DECIDE PC intervention versus standard care in improving palliative care outcomes, including quality of life, receipt of quality communication, advance care planning documentation/discussion, and hospice use, and 2. evaluate contextual factors that influence the effectiveness, fidelity, and adoption of the DECIDE PC intervention. We anticipate this work will establish the effectiveness of a CHW-based palliative care intervention in a priority population and generate generalizable knowledge to guide the development and implementation of interventions to increase the use of palliative care services in underserved populations.